Fatime Sonogo documentation Assignment : Maternity case 10 (complex)

Maternity Case 10: Fatime Sanogo (Complex)
Documentation Assignments


1. Document your initial assessment data for Ms. Sanogo, including vital signs, fundal
assessment (consistency, position, location), lochia assessment (amount, color, odor,
consistency), and pain (location, quality, severity).

Ms. Sanogo’s initial vital signs are as follows: Heart rate: 100. Pulse: Present. Blood pressure:
98/50 mmHg. Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C.

States pain is a 5/10 located in her “belly”. Initial fundal massage indicated uterus did not
properly firm up. Bladder scan showed retained urine. Performed straight catheterization and
emptied 300 ml urine. Assessment of bed pads showed significant change in output of blood.
Weight of bed pads suggested approximately 1270 ml lochia. Time since last change suggested
bleeding rate of 1980 ml/hr. Second palpation of fundus indicated uterus was soft and boggy.
Perineum assessed: minimal redness, minimal edema and no discharge from tear. Significant
amount of blood and lochia noted.



2. Write the situation-background-assessment-recommendation (SBAR) communications you
would use to update the provider on Ms. Sanogo’s status after your first encounter with
her.

Ms. Sanogo is a 23 year old primiparous female in her first hour after vaginal delivery. She has a
prolonged second-stage labor. She has a second-degree perineal laceration that has been
repaired. The placenta was delivered manually. Bleeding was controlled by fundal massage and
infusion of oxytocin that is still running at 20 ml/hr. She was not able to void. Bladder scan
showed 300 ml retained in bladder. This RN performed straight catheterization.

3. Document the medication(s) you administered to Ms. Sanogo and evaluate each
drug’s effectiveness.

2 mg butorphanol tartrate IV for pain: did provide pain relief
500 ml lactated Ringers IV bolus given over 5 minutes: no change in BP or HR status
Oxytocin postpartum at 500 ml/hour
5 mg morphine IV: provided more pain relief

, 4. Document the sequence of events during the simulation (i.e., vital signs, assessment
findings, blood loss, nursing interventions, and patient response).

You arrived at the patient.
0:00 You introduced yourself.
0:07 You washed your hands. To maintain patient safety it is important to wash your hands
as soon as you enter the room.
0:10 Patient status - Heart rate: 100. Pulse: Present. Blood pressure: 98/50 mmHg.
Respiration: 18. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: --. Fetal heart
rate:
--.
0:45 You identified the patient. To maintain patient safety it is important that you
quickly identify the patient.
0:56 You asked if the patient was allergic; to anything. (In pain) She replied: “No, I am
not allergic to anything”
1:10 Patient status - Heart rate: 102. Pulse: Present. Blood pressure: 100/51 mmHg.
Respiration: 19. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: --. Fetal heart
rate:
--.
1:19 You attached the automatic noninvasive blood pressure (NIBP) measurement cuff.
This will allow you to reassess the patient continuously.
1:23 You looked for normal breathing. She is breathing at 19 breaths per minute. The chest
is moving equally.
1:51 You attached the pulse oximeter; This was indicated by order.
2:03 You checked the radial pulse. The pulse is strong, 105 per minute and regular. It
is correct to assess the patient’s vital signs.
2:10 Patient status - Heart rate: 103. Pulse: Present. Blood pressure: 99/50 mmHg.
Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: --. Fetal heart
rate:
--.
2:26 You checked the Temperature; at the mouth. The temperature was 37 C.
2:53 You listened to the lungs of the patient. The breath sounds are clear and
equal bilaterally.
3:10 Patient status - Heart rate: 105. Pulse: Present. Blood pressure: 97/49 mmHg.
Respiration: 20. Conscious state: Appropriate. SpO2: 96%. Temp: 37 C. EFM: --. Fetal heart
rate:
--.
3:15 You listened to the heart of the patient. This is reasonable. There were regular
heart sounds without murmurs.
3:32 You assessed the patient’s IV. The site had no redness, swelling, infiltration, bleeding,
or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has
is always important.
3:57 You asked the patient if she had any pain. (In pain) She replied: “Yes! Ahh...”